99-2-0E Registration – Demographics Existing Patients – CommunityMed Family Urgent Care

CMed – Enter Patient Demographics

Form 219

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HID Traffic Source

this variable shows where traffic came to this form from. Query string variable is checkinid

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DO WE NEED? HID Arrived

this variable is set to 4 when patient has arrived in the parking lot. the querystring variable is arvd. Default value is 0

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Visit ID

visit id passed to this form by booking

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Patient ID

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HID Decimal Time

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Today Date

captures the date of entry for use in calculations

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Tomorrow Date

captures the date of entry for use in calculations

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HID Pull Visit

this pulls the visit record written by booking based on the Visit ID

Patient Details

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Patient Name(Required)

First Last

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Patient Date of Birth(Required)

Confirm Patient (or parent for minors) Mobile Phone(Required)

Confirm Patient (or parent for minors) Email(Required)

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Patient Age

Address Info

Confirm the address below(Required)

I confirm the address below is my legal address AND THE ADDRESS ON MY DRIVERS LICENSE

I confirm the address below is my legal address BUT IT IS NOT the address on my drivers license, my license is wrong

The address below is INCORRECT, and I will update it below and save it

PATIENT Legal Address (address in public records e.g. drivers license)(Required)

Street Address Address Line 2 City State ZIP Code

Patient Demographics

For Identification purposes, please enter the social security number below. We hold this value in confidence.

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Parent or Guardian Social Security Number

Information is used for billing – will be kept confidential

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Patient Social Security Number

Information is used for billing – will be kept confidential

99-2-0E Registration – Demographics Existing Patients

CMed – Enter Patient Demographics

Patient Details

Address Info

Patient Demographics

Select Pharmacy

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